Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia?

Published:February 11, 2021DOI:


      Vascular limb salvage services are recommended by the Global Vascular Guidelines to help improve outcomes for patients with chronic limb-threatening ischaemia (CLTI), although their description within the literature is limited. This study reports the 12 month outcomes for an outpatient based vascular limb salvage (VaLS) clinic.


      An analysis of a prospectively maintained database, involving all consecutive patients diagnosed with CLTI within the VaLS clinic from February 2018–February 2019, was undertaken. Data were compared with two comparator cohorts, identified from coding data: 1) patients managed prior to the clinic, between May 2017 and February 2018 (Pre-Clinic [PC]); and 2) patients managed outside of clinic, between February 2018 and February 2019 (Alternative Pathways [AP]). Freedom from major amputation at 12 months was the primary outcome. Kaplan–Meier plots and adjusted Cox’s proportional hazard models (aHR) were used to compare outcomes.


      Five hundred and sixty-six patients (VaLS 158, AP 173, PC 235) were included (median age 74 years). Patients managed within the VaLS cohort were statistically significantly more likely to be free from major amputation (90.5%) compared with both the AP (82.1%, aHR 0.52, 95% confidence interval [CI] 0.28 – 0.98, p = .041) and the PC (80.0%; aHR 0.50, 95% CI 0.28 – 0.91, p = .022) cohorts at 12 months, after adjustment for age, disease severity, and presence of diabetes.


      This study supports the recommendations of the Global Vascular Guidelines that vascular limb salvage clinics may improve the rate of major amputation. Furthermore, the study provides a reproducible service model that delivers timely vascular assessment in an ambulatory setting. Further evaluation is required to assess longer term outcomes.


      To read this article in full you will need to make a payment


        • Chung J.
        • Modrall J.G.
        • Ahn C.
        • Lavery L.A.
        • Valentine R.J.
        Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia.
        J Vasc Surg. 2015; 61 (e161): 162-169
        • Musuuza J.
        • Sutherland B.L.
        • Kurter S.
        • Balasubramanian P.
        • Bartels C.M.
        • Brennan M.B.
        A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers.
        J Vasc Surg. 2020; 71: 1433-1446
        • Nickinson A.T.O.
        • Bridgwood B.
        • Houghton J.S.M.
        • Nduwayo S.
        • Pepper C.
        • Payne T.
        • et al.
        A systematic review investigating the identification, causes and outcomes of delays in the management of chronic limb threatening ischaemia and diabetic foot ulceration.
        J Vasc Surg. 2020; 71: 669-681
        • Normahani P.
        • Mustafa C.
        • Standfield N.J.
        • Duguid C.
        • Fox M.
        • Jaffer U.
        Management of peripheral arterial disease in diabetes: a national survey of podiatry practice in the United Kingdom.
        J Foot Ankle Res. 2018; 11: 29
        • Sanders A.P.
        • Stoeldraaijers L.G.
        • Pero M.W.
        • Hermkes P.J.
        • Carolina R.C.
        • Elders P.J.
        Patient and professional delay in the referral trajectory of patients with diabetic foot ulcers.
        Diabet Res Clin Pract. 2013; 102: 105-111
        • Pankhurst C.J.W.
        • Edmonds M.E.
        Barriers to foot care in patients with diabetes as identified by healthcare professionals.
        Diabet Med. 2018; 35: 1072-1077
        • Vascular Society of Great Britain and Ireland
        A best practice clinical care pathway for peripheral arterial disease.
        (London)2019 (Available at:)
        • Conte M.S.
        • Bradbury A.W.
        • Kolh P.
        • White J.V.
        • Dick F.
        • Fitridge R.
        • et al.
        Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.
        Eur J Vasc Endovasc Surg. 2019; 58 (S1–S109.e133)
        • Rogers L.C.
        • Andros G.
        • Caporusso J.
        • Harkless L.B.
        • Mills Sr., J.L.
        • Armstrong D.G.
        Toe and flow: essential components and structure of the amputation prevention team.
        J Vasc Surg. 2010; 52: 23S-27S
        • Fitzgerald R.H.
        • Mills J.L.
        • Joseph W.
        • Armstrong D.G.
        The diabetic rapid response acute foot team: 7 essential skills for targeted limb salvage.
        Eplasty. 2009; 9 (e15-e15)
        • Nickinson A.T.O.
        • Houghton J.S.M.
        • Bridgwood B.
        • Essop-Adam A.
        • Nduwayo S.
        • Payne T.
        • et al.
        The utilisation of vascular limb salvage services in the assessment and management of chronic limb threatening ischaemia and diabetic foot ulceration: a systematic review.
        Diabetes Metab Res Rev. 2020; 36: e3326
        • Mills Sr., J.L.
        • Conte M.S.
        • Armstrong D.G.
        • Pomposelli F.B.
        • Schanzer A.
        • Sidawy A.N.
        • et al.
        The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI).
        J Vasc Surg. 2014; 59: 220-234.e222
        • Baubeta Fridh E.
        • Andersson M.
        • Thuresson M.
        • Sigvant B.
        • Kragsterman B.
        • Johansson S.
        • et al.
        Editor's Choice – Impact of comorbidity, medication, and gender on amputation rate following revascularisation for chronic limb threatening ischaemia.
        Eur J Vasc Endovasc Surg. 2018; 56: 681-688
        • Harding J.L.
        • Pavkov M.E.
        • Magliano D.J.
        • Shaw J.E.
        • Gregg E.W.
        Global trends in diabetes complications: a review of current evidence.
        Diabetologia. 2019; 62: 3-16
        • Khan A.
        • Hughes M.
        • Ting M.
        • Riding G.
        • Simpson J.
        • Egun A.
        • et al.
        A ‘hot clinic’ for cold limbs: the benefit of urgent clinics for patients with critical limb ischaemia.
        Ann R Coll Surg Engl. 2020; 102: 412-417
        • Flores A.M.
        • Mell M.W.
        • Dalman R.L.
        • Chandra V.
        Benefit of multidisciplinary wound care center on the volume and outcomes of a vascular surgery practice.
        J Vasc Surg. 2019; 70: 1612-1619
        • Armstrong D.G.
        • Bharara M.
        • White M.
        • Lepow B.
        • Bhatnagar S.
        • Fisher T.
        • et al.
        The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot.
        Diabetes Metab Res Rev. 2012; 28: 514-518
        • Zamani N.
        • Chung J.
        • Evans-Hudnall G.L.
        • Martin L.A.
        • Gilani R.
        • Poythress E.L.
        • et al.
        Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers.
        J Vasc Surg. 2020; ([Epub ahead of print])
        • Horrocks M.
        GIRFT Programme National Specialty Report.
        (London)2018 (Available at:)
        • The Royal College of Radiologists
        Clinical radiology UK workforce census report 2018.
        (London)2019 (Available at:)
        • Noronen K.
        • Venermo M.
        • Saarinen E.
        • Alback A.
        Analysis of the elective treatment process for critical limb ischaemia with tissue loss: diabetic patients require rapid revascularisation.
        Eur J Vasc Endovasc Surg. 2017; 53: 206-213
        • Hirsch A.T.
        • Criqui M.H.
        • Treat-Jacobson D.
        • Regensteiner J.G.
        • Creager M.A.
        • Olin J.W.
        • et al.
        Peripheral arterial disease detection, awareness, and treatment in primary care.
        JAMA. 2001; 286: 1317-1324
        • Subherwal S.
        • Patel M.R.
        • Kober L.
        • Peterson E.D.
        • Jones W.S.
        • Gislason G.H.
        • et al.
        Missed opportunities.
        Circulation. 2012; 126: 1345-1354
        • Saratzis A.
        • Jaspers N.E.M.
        • Gwilym B.
        • Thomas O.
        • Tsui A.
        • Lefroy R.
        • et al.
        Observational study of the medical management of patients with peripheral artery disease.
        Br J Surg. 2019; 106: 1168-1177
        • Herbert A.
        • Wijlaars L.
        • Zylbersztejn A.
        • Cromwell D.
        • Hardelid P.
        Data Resource Profile: Hospital Episode Statistics Admitted Patient Care (HES APC).
        Int J Epidemiol. 2017; 46 (1093–1093i)
        • Darling J.D.
        • McCallum J.C.
        • Soden P.A.
        • Korepta L.
        • Guzman R.J.
        • Wyers M.C.
        • et al.
        Results for primary bypass versus primary angioplasty/stent for lower extremity chronic limb-threatening ischemia.
        J Vasc Surg. 2017; 66: 466-475